I reckon half the problem with the teaching process when it comes to the "clinicaql approach" or your standardised approach to the pt, is that people get bogged down in what they think they're supposed to be doing and the specific order of everything, that they forget to just talk to the people.
First impression dictates a lot. I have a book for medical interns called "On call" which calls it the quick look test, which I like.
My approach, for what its worth, is similar to John's. I suppose this is an adequate reflection. It feels odd to put it down on "paper" like this.
Quick look test: Are they "Big sick", "little sick", or "not sick". Just a gut feeling, it can and should be revised later. Based largely on responsiveness as I enter the room and skin colour. To me:
-Big sick, means the next step is a formal primary survey.
-Little sick means I take their vitals during my initial chat to them and I'm a bit more direct.
-Not sick* (most pts) generally means I'm sitting down if possible and doing five minutes or more of history taking before I even bother with vitals.
Initial approach (+/- vitals) :For little sick and not sick: Introduce myself and my partner. Get their name. Shake their hand (Is their hand warm? Mental status adequate to follow the social norm? Plus old blokes like it). Ask them what brings me here today. I don't follow a particular set of questions initially, I just prompt them into painting a clearer picture of all the events and timing surrounding the chief complaint and associated symptoms. With each problem I ask, 1) Is it new or normal for them? 2)Have they ever felt anything like it before? Once they've listed all their complaints, I then run through the pertinent negatives. Chest pain? SOB? Dizzy? Palpitations? Nausea? etc based on what they've said. As I said, if they're little sick or I have MICA coming, I'll do some vitals simultaneously.
Targeted hx and physical (+/- vitals):Then based on what they've said, a differential will appear in my head, I start with targeted hx of physical exam looking at knocking things off/up that list. I have a standard set of questions/exams that I do for common serious problems, that will generally come first if any of them are in my ddx.
For a stroke symptom for example the standard set is: GCS, BSL. Pupils, visual acuity. Swallowing? Any trouble hearing? Head/neck pain? Any stroke/TIA hx? Strength/sensation in each limb? Have them walk across the room and back. Trouble walking/balance/dizziness/vertigo?
Look at their meds and have a quick word about their medical hx in general. Specifically prompt common problems. MI, stroke, COPD, asthma, diabetes etc.
Decisions: Then comes a decision on a working diagnosis and what care pathway is appropriate for them (Self care, GP, some kind of community based health service, LOCUM, case worker, hospital, direct admission, Intensive care paramedic back up, Chopper).
Thoroughness: A more thorough hx and physical will then follow in the truck if we transport, if not, we'll do it on scene. Involves general hx taking that pretty much everyone gets. Opening bowels/micturition, oral intake, exercise, recent coughs/colds/flu like symptoms etc, sleeping patterns, recent falls, hospital admission in the past 5 years, surgeries (a lot of this is more for older people) if they weren't already part of the targeted hx.
I dunno how well this really reflects how I go about it, but its seems like a reasonable sketch.
I standardised certain questions sets so I could get things done, quicker with greater consistency while being paralytically tired. Its worked well for me as a newbie so far and I'd recommend it in some way shape or form.
*Doesn't actually mean their is nothing wrong with them. Its just a play on the idea that most shifts, I'll go to multiple jobs where I walk into a room with a few people in it and have to ask to who the patient is because every one looks perfectly healthy.
